The Marketing of Fear

AUSTRALIAN FINANCIAL REVIEW

By Ray MoynihanJune 10, 2000

When the pharmaceutical industry threw a lunch for some friends earlier this year, it was nothing but the best. Sushi and caviar were on the menu as drug company staff mingled freely with representatives of the Arthritis Foundation, diabetes and cancer groups inside Sydney's plush Hotel Inter-Continental. The gathering was part of a plan to build "constructive and lasting alliances " to improve the "quality [of] health care for patients and their carers", according to a memo from the Australian Pharmaceutical Manufacturers Association.

Set up by drug companies, the so-called Patient-Industry forum is part of a global push to get closer to those who use their products. A big part of that push right now is an attempt to win the right to advertise prescription pills directly to consumers, a practice banned in Australia.

In the United States, companies are allowed to advertise their drugs direct to the public, and billions of dollars are being spent on slick prime-time TV commercials and full-page newspaper and magazine ads.

While industry wants to overturn the Australian ban, elements within the consumer movement are strongly opposed to allowing advertising or promotion in any form.

In the middle is the respected health expert, Rhonda Galbally, who is finalising a review of the rules and due to report to federal and State governments in the next two weeks.

But even before Galbally's report is written, pharmaceutical companies are aggressively pushing their agenda. Roche attracted headlines last month for sponsoring an "educational" campaign on TV about obesity, which was in fact a thinly disguised promotion for one of its new products. Now Merck Sharp & Dohme is targeting consumers with saturation advertisements about hair loss, and at the same time marketing a prescription pill for the "condition".

A combination of advertising and company-sponsored education, possibly developed in partnership with public health bodies, is favoured by the APMA, the industry's peak body. Its chief executive, Alan Evans, told The Australian Financial Review on his first day in the job earlier this year: "There is increasing demand from consumers to know what it is they are taking, and advertising will enable drug manufacturers to meet that demand."

This week, however, the industry didn't want to be seen to be pushing too hard for a lifting of the ban on advertising. A spokesperson for Evans said:

"The industry is still forming a position on the issue. We will need to consider the Galbally review findings and also consult widely with relevant stakeholders before arriving at a position."

One of the most powerful stakeholders is the Australian Consumers Association, whose opposition to direct-to-consumer advertisements and promotions has hardened in recent months. Like other consumer groups, the ACA wants information about medicines to be made more widely available, but it doesn't believe advertising provides useful information.

A senior health policy officer with the ACA, Nicola Ballenden, is particularly wary about company-sponsored educational campaigns. "The evidence is, once you open the gate, companies throw resources behind growing their market," she says. "The danger with educational campaigns could be that consumers are persuaded they have a problem when they don't, which is another way of inducing demand for their products."

The idea of companies educating the public about diseases, as Roche is doing with its obesity campaign, is highly controversial. Looked at from one perspective, industry is responsibly raising awareness about important problems. Looked at from a different angle, companies are skewing the public debate towards drugs to expand the markets for their products.

For many health problems, there is a range of solutions. The latest, most expensive drug is only one of many and is not always the best.

In Canada, researchers at the University of British Columbia have provocatively described company-sponsored awareness raising about osteoporosis as the "marketing of fear". Put simply, osteoporosis is the thinning of the bones as people age that increases the risk of fracture. But some health experts don't regard it as a "disease" at all.

The Canadian researchers, led by Associate Professor Arminee Kazanjian, have also raised concerns about the way a combination of advertisements and magazine articles engender fears about heart disease in women, and then subtly encourage the use of cholesterol-lowering drugs as the solution.

The review of advertising rules here is part of a broader competition review being conducted for the Council of Australian Governments. While the chair is strongly in favour of more accessible information for consumers, Galbally is concerned about the potentially adverse effects of advertising on public health.

"I have no objection to business being created through advertising in the media, but I do if it is at the expense of people's health and well-being. If people are going to be plagued by uncertainty and misery about their health, and fear about potential disease that may or may not eventuate, in order to sell products, that's a very different matter from being informed about new developments in medicine," says Galbally, the managing director of Melbourne University's Australian International Health Institute.

"We have yet to develop a mechanism to safely open up an information channel. It would be great to think industry and public health interests could work out [together] how to deliver information that is not about persuasion. I'm worried, though, that that is idealist, and in the real world it could be the beginning of a slippery slope towards open slather."

"Open slather" is a shorthand way of describing the experience in the US, where companies are spending more than $US1 billion a year to promote drugs and diseases direct to the public. Nightly news broadcasts are peppered with ads about erectile dysfunction for men and the horrors of menopause for women  including a high-rotation commercial featuring fearful warnings about women's teeth falling out.

Powerful prescription drugs for stomach troubles, baldness and depression are routinely advertised on TV, in magazines like Time and in mass-circulation daily newspapers.

Survey data suggest that as a result of the ads, people visit their doctors and successfully demand products by name. Supporters say consumers are better informed, leading to undiagnosed disease being discovered and treated; critics worry about an increase in unnecessary prescribing. But at this stage there is very little research on how advertising affects people's health.

What is clear is that many of the ads and promotions reaching mass audiences are grossly misleading because they lack fair balance.

The US Food and Drug Administration requires advertisers to provide balanced coverage of both benefits and risks. But bizarre as it may seem, the FDA writes to companies that have violated this requirement after the ads are broadcast or published, and as long as the ad is withdrawn, no penalties apply.

A Glaxo TV ad that was misleading because it suggested that its flu drug, Relenza, "is more effective than has been demonstrated by substantial evidence".

SmithKline Beecham's distribution of a T-shirt advertising its anti-depressant at a children's health fair.

A TV ad for Schering Corporation's big-selling Claratin, which made some information difficult to read by having "white type against a white background".

A Merck ad that was "misleading because it suggests, without substantial supporting evidence, that Propecia therapy is guaranteed to prevent hair loss in men".

Merck promotional materials about its bone-building osteoporosis product, Fosamax, that were found to be "misleading" because they failed "to present important risk information regarding reports of serious oesophageal adverse experiences ".

The FDA was so concerned by Merck's repeated violations that it suggested the company had "a corporate policy towards minimising the presentation" of balanced information, commonly failing to present "information relating to contraindications, warnings and other risk information with a prominence and readability reasonably comparable to the information relating to the effectiveness of the drug".

Last year, The New York Times ran a special report about the FDA warning letters, finding the most common problems were that ads overstated benefits and played down side effects. While this is hardly surprising, it does underline the fundamental difference between information designed to educate and advertising designed to sell.

Pharmaceutical companies operating in Australia are at pains to point out that they are not advocating the "open slather" situation of the US. The APMA's Evans says: "We are not going to be asking for something that would be culturally inappropriate."

But there is little doubt the industry wants to be allowed to promote much more directly to consumers, worldwide.

A special report prepared in 1999 by a global management consultancy, Boston Consulting Group, suggests the pharmaceutical industry must become more consumer focused and develop "loyal consumer franchises in which consumers look to the company for continuing care and support".

In the chapter titled "Consumer-Centric Care", the report asserts: "Companies can drive demand by providing continuous, targeted support for each consumer decision point A different range of tools will be available in each market, from materials in hospitals and physicians' offices, to direct mail, to print and television advertising, to diagnostics, to partnerships with affinity groups."

"Partnership" is becoming a buzzword, but tensions will inevitably emerge between consumer groups like the ACA, which don't accept drug company money, and groups like the Arthritis Foundation, which do.

The chief executive of the Arthritis Foundation of Australia, Ian Hook, says the partnership that drug company sponsorship brings allows patient groups to raise awareness more effectively. "The money helps the community recognise there are services available, and helps channel sufferers to good information and self-management services."

But as all those on the receiving end of drug company largess well know, no free lunch is entirely free.

The global consumer group Health Action International has become so concerned about the dangers of accepting drug company sponsorship that a meeting was organised in Paris in late 1998, which led to a publication called The Ties That Bind. The foreword argues that all sponsorship should be clearly recognised as a form of promotion.

One speaker at the Paris conference, Barbara Mintzes, suggested that companies could use patient groups "to spread awareness about new drugs reach consumers directly, bypassing doctors and they can provide a more credible endorsement for a product than could be achieved if it came directly from the company itself". Canadian-based Mintzes, who will visit Australia in the coming months, wrote a damning report on the dangers of direct-to-consumer advertising in 1998 called Blurring the Boundaries: New Trends in Drug Promotionals, which was published by the Amsterdam-based HAI.

An APMA spokeswoman says the Patient-Industry forum in Australia has nothing to do with moves to try to advertise direct to consumers but is all about improving health outcomes by, for example, increasing compliance. Guidelines are being developed to govern the relationships between consumer groups and companies, she says.

Within a couple of weeks, Galbally's report will be widely available, and the decision to lift the prohibition on advertising direct to the public will become a political one. While some in Canberra will be attracted to the idea of loosening restrictions, ministers are mindful of the potential impact this would have on an already burgeoning Pharmaceutical Benefits Scheme.

For its part, the Federal Opposition is strongly opposed to advertising, believing it could lead to a needless increase in sales.

Whatever happens in Australia, if the Boston Consulting Group report is anything to go by, pharmaceutical company executives and shareholders have much to look forward to. The report optimistically predicts that in the new century, pharmaceutical therapies will "become available for previously untreated health and quality-of-life conditions".